How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis

Abstract Historically, recordkeeping has been an essential task for health professionals. Today, this mandatory task increasingly takes place as digital documentation. This study critically examines problem constructions in practical documents on digital documentation strategies in Danish municipal healthcare and how these problem constructions imply particular solutions. A document analysis based on the approach presented in Bacchi's “What's the problem represented to be?” was applied. Forty practical documents in the form of guidelines, strategies, and quality control documents were included. The analysis uncovered three problem representations: lack of coherence between health services in a complex healthcare system, lack of assessable data for management and political prioritization, and inefficiency in the healthcare system. The proposed solution is a digitalized and standardized practice that transforms recordkeeping in the municipalities. However, municipal healthcare is at risk of being fragmented due to digital documentation's focus on the organizational management of health with task‐oriented practices supplied by an anonymous health professional. We find that digital documentation functions as an organizational micromanagement approach that assigns the health professional a subject position as an employee acting according to the organization's framework rather than the profession's normative framework.

care and affect health professionals' digital documentation practices.

| BACKGROUND
Documentation has a long tradition in health professionals' practice.
The first medical records date back to Egypt in 1600 BC (Doyle-Lindrud, 2015;Evans, 2016). In the 1970s, a transition began as computer technology was introduced (Evans, 2016). By the end of the 1990s, almost all healthcare organizations in developed countries had a digital system that supported healthcare professionals (Watson, 2016). A key aspect of this digitalization is the Electronic Health Record (EHR) which is a vital component of health informatics (Braunstein, 2015). According to Petrakaki et al. (2016), healthcare documentation often relates to accomplished clinical procedures and informs health professionals about treatment and care. Today, almost all healthcare professionals worldwide document and communicate in the EHR (Menvielle et al., 2017). Historically, the term "recordkeeping" has been used in healthcare to define the process of submitting written information between health professionals. Over time, the term has been replaced by "documentation." As we show in this article, this reflects a transformation of the meaning of documentation practices. For simplicity, the term "documentation" is used to designate both processes in this article.

| Documentation in healthcare practice
Research indicates that there are many benefits for care, treatment, and patient experience when health professionals record their actions in journals. Studies show that healthcare documentation plays a vital role in patient safety and risk prevention (Blair & Smith, 2012;King et al., 2014), mainly when documentation in EHRs supports organizational workflow and provides health professionals with necessary knowledge (Eklöf et al., 2014). Even so, documentation procedures are not straightforward; a recent study showed that from 2016 to 2019, 69% of inspected institutions in Danish home care and care homes had insufficient documentation (Hertzum, 2021).
Other studies have focused on barriers to documentation and potential consequences. For example, Alexander (2015) examined how nursing assistants communicate using notes and pictures in addition to electronic records to prevent skin ulcers, while Stevenson (2018) concluded that unsuitable structures in EHRs resulted in workarounds when health professionals tried to ensure patient safety.
Research has also focused on topics related to the transformation from analog to digital documentation, for example, time-saving issues (Baumann et al., 2018;McCarthy et al., 2019), the correlation between standardized frameworks and quality (Blair & Smith, 2012), digital documentation as a cost-saving practice (Adler-Milstein et al., 2013;Zlabek et al., 2011), and the relation between digital standardization and concrete practice (Johnson et al., 2012;Winman et al., 2012).

| Focus and aim
In practice, management, and research, the most prevalent assumption seems to be that these practical documents represent "neutral" descriptions of pre-existing problems that digitalization can help solve. In taking our epistemological starting point in the tradition of poststructuralism, we assume that digitalization creates the framework by which problems related to documentation are mentally and linguistically formed and perceived. A poststructuralist approach facilitates an analysis that is open to a plurality of practices, discourses, and possibilities. With this emphasis on contingencies, the subject of healthcare documentation can be perceived as an ongoing process. Thus, we expected that the practical documents take part in constructing the problems that digitalization is expected to solve, where problem representations construct digital documentation as a particular kind of practice. Against this backdrop, the aim of this article was to explore how problems are constructed in practical digital health documentation in the municipal health service and how these problems present particular solutions for health professionals.

| METHODS
The study was conducted as a document analysis using Bacchi and Goodwin's "What's the problem represented to be?" (WPR) approach.
According to this, practical documents are manufactured, consumed, and function in social practice to inform people about how to act (Bacchi & Goodwin, 2016, p. 34;Prior, 2003). The study was based on the poststructuralist premise that the solutions presented in practical documents are not just reactions to existing problems, but that the documents in presenting solutions construct problems as particular problems (Bacchi, 2009).

| Documents
To identify relevant practical documents, a search was first performed on
The first question helped us work backwards from the proposed digital solutions and strategies presented in the documents to examine which problems the solutions were expected to address.

| The solution to lack of coherence, data, and inefficiency
In the four selected documents, digital healthcare documentation appears to be the solution to most problems in the healthcare system.
However, three problems stand out distinctly: (1) Lack of coherence between health services (2) Lack of assessable data for management and political prioritization (3) An inefficient healthcare system 4.1.1 | Lack of coherence between health services Lack of coherence between health services in the healthcare system is represented as a problem in two ways (Sundheds-og AEldreministeriet, 2018, p. 8): as an issue related to citizens' individual experiences and as an organizational issue for the healthcare system.
Coherence between health services appears to indicate quality in the healthcare system and is expected to be achieved by digital infrastructure, creating a digital network that contains digital highways for data and communication (Sundheds-og AEldreministeriet, 2018, p. 14). The suggested solution for both issues is digitalized "data" storage, which is expected to enable efficient information sharing across time and place: "[…] we need to provide healthcare employees with easy, secure access to relevant knowledge so that they interact with the patient in the most expedient manner possible." 1 (D1, p. 18). It is assumed that coherence is achieved when knowledge and information regarding citizens are digitally shared among health Sundheds-og AEldreministeriet, 2016). Common to the documents is an emphasis on the idea that written information leads to knowledge, subsequently leading to coherence, diverting attention from the physical presence of health professionals or other forms of collaboration as a source of information sharing. As such, words, phrases, or actions that relate to "meetings," "team meetings," "feedback," or "handover" are not present in any of the central documents.

| Lack of assessable data for management and political prioritization
The second problem is lack of assessable data for management and political prioritization (D1, D2, D3, D4). The proposed solution is to standardize information in the EHR, as this is expected to enable data extraction. The assumption is that organizations need "valid data" (D2) to control costs and resources.
Generally, "data" are a relatively open concept that can be "filled with different meanings" (Bacchi, 2009, p. 8). In these documents, "data" are exclusively used for standardized and classified information and connotes instrumental and quantified healthcare. Via standardization, healthcare documentation is expected to transform into extractable data related to quality, economics, and statistics (D2). The assumption is that health professional documentation can be used to prove that certain healthcare activities have taken place, but only if it is standardized through "classifications" (D2, p. 19).
This problem representation can be traced back to the first digitalization strategy (Sundhedsministeriet, 1999)  the government and the municipalities claims that financial difficulties can be solved by "better documentation" of the tasks and "systematic evaluation" of finances and efficiency (Finansministeriet, 2004, p. 16). What is referred to in this document is not recordkeeping but documentation as "proof of performance of tasks." In the following year, 2006, the focus was on professional documentation in the form of knowledge about "task solution," "benchmarking," and "achieving goals" (Finansministeriet, 2006, pp. 10, 25). The articulation of the need for data accelerated with the socalled partnership project between KL-Local Government Denmark The assumption is that with the introduction of digital documentation methods, valid data will be obtained. There is a silencing of the idea that health professionals can simply opt out of following the structures, documenting instead in other classifications-or not documenting at all. The standardization of documentation is presented as the desirable scenario, disregarding the possibility that health professionals may choose not to follow this path.

| An inefficient healthcare system
The third problem representation is what we term "an inefficient First, citizens must be assessed for what is "relevant" (D2). It is not explicitly described for whom it may be relevant. Still, the criterion of "relevance" seems implicitly to be for the organizations, and services must be relevant for the citizens' recovery. Services have a specific aim in the form of an "expected condition" (D2) and are monitored continuously to assess whether services should continue or end. The CLP functions as an organizational algorithm that standardizes the care trajectory when citizens' needs are assessed via "conditions." Visitation of services takes its starting point from the service catalog, and the trajectory is planned with an "expected condition"(D2). The Efficiency has been increasingly in focus over the years, especially with the political reform of the healthcare system in 2007 (Indenrigs- og Sundhedsministeriet, 2005a), resulting in a distribution of responsibility and increasing task loads in municipalities without financial compensation (Finansministeriet, 2004(Finansministeriet, , 2006(Finansministeriet, , 2014. In 2010, KL-Local Government Denmark wrote: "The municipalities face three significant challenges at the same time: fewer resources, more difficult recruitment, and expectations of higher quality in welfare services. The municipalities must find an answer to this, and one of the essential tools in the coming years will be digitalization" (Kommunernes Landsforening, 2010a, p. 10).
It is silenced that documentation can occur in other media than digital, for example, on written paper notes in homes or offices. On the contrary, it appears that documentation has to be digital to be converted into useful data. With this, the documents construct a dichotomy between "digital practice," which is explicitly described with positive connotations, and "analog practice," which implicitly appears to be its negative counter-image:

| Effects
The effects of these three problem representations are intertwined across the representations. Below, we present them in three main categories.

| A citizen's journey in a seamless system
One effect of this way of discursifying digital documentation is that the citizen's care trajectory is constructed as a journey in a supposedly seamless healthcare system. Information is constructed as a critical aspect for creating coherence, and is provided by the history throughout the healthcare system. Citizens-patients and relatives-must be able to expect the healthcare professionals they meet to know the relevant information" (D1, p. 18). The citizen is constructed as a consumer who has the right to expect and demand certain health services delivered from the healthcare system. Good service or good quality is equivalent to a seamless system. Moreover, the health professionals' job is to ensure this seamless experience.

| The governed health professional
A second effect is that health professionals are constructed as governed by management. The importance of standardized documentation practice is bound by a managerial interest in valid data (Kommunernes Landsforening, 2010b), and is based on the conceptual logic that digitalization creates more value for money (Regeringen et al., 2007). The CLP document constructs an organizational hierarchy between health professionals, signifying that documentation practices are independent of professional competencies. The hierarchy is described by consistent use of two organizational roles: "public authority" and "supplier" (D2, p. 8). The authorities are described as being "[…] responsible for follow-up and assessment of the expected condition(s)" (D2, p. 11). According to the documents, the public authority carries the organizational role of concrete daily prioritization within the given framework of the organization. In contrast, the supplier's task is to receive orders, and plan and execute the services. The supplier is not given responsibility for assessment or prioritization, but "[…] must ensure that the citizen's conditions and instructions for action are updated if there are changes in the citizen's situation. Follow-up by the authority depends on the citizen's information being updated" (D2, p. 12).
Thus, the health professional is placed in a subject position as an actor that represents an organization, and not representing a specific profession. Furthermore, with the CLP, documentation practice is framed as an organizational activity in contrast to documentation as a health professional activity defined by professional knowledge, norms, and values.

| Standardization
Central elements in standardization are "health conditions" and "functional Strictly professional documentation, only for professionals' use, is described as "documentation for the sake of documentation" (Kommunernes Landsforening, 2002, p. 10), which implies that documentation without a managerial purpose is a waste of valuable time. A discursive effect is that previous professional documentation practice (nonstandardized and patient-oriented) appears to be inappropriate. The "right kind" of documentation is constructed as short, strict, and reflecting the correct classifications. The classifications implemented with the introduction of digital systems contribute to a specific form of standardization of professional language. The term "minimum data set" (D2, p. 17) is used to characterize some kinds of documentation as being more significant than others. Observations or actions based on the health professional's tacit knowledge or professional gaze become nonexistent, as there is no room for this in the EHR.
Thus, the categories construct a "task-oriented" practice, framing healthcare practice through certain activities produced by health conditions. It is only possible to assess citizens' needs through predefined conditions, and it is impossible to assign a task if it does not fit the predefined categories.

| DISCUSSION
Problem representations implicate materializations "into the real" (Bacchi & Goodwin, 2016). In our case, several subtypes of standardization materialize in municipal healthcare. First, the CLP defines a uniform nationwide design of the EHR. Second, the CLP´s specific terminology builds upon certain classifications (D2, p. 15). Third, the CLP performance standards define specific roles and tasks, creating procedural standardization, and specifying which actions are appropriate at particular times (D2). Fourth, the Quality Control documents act as performance standards, providing indicators for quality control (D3, D4). The overall effect is that the digital documentation functions as organizational micromanagement (Cleary et al., 2015) of municipal healthcare to create value (Lega et al., 2013). The health professionals are offered the subject position of "deliverer" or "employee," and procedural standardization operates as an organizational tool to guide concrete workflows and healthcare services, leading to what other researchers have termed a LEAN-line practice (Crema & Verbano, 2016;Hung et al., 2021). In general, health professionals are characterized as performing their duties while having dual loyalty to the state and citizen, while their practice is guided by a profession-specific normative framework (Grimen, 2006;Hjort, 2012). According to Kijne and Frederiksen (2019), health professionals' normative framework centers on the concept of caring and is based on an implicit contract to behave according to certain norms resulting in unspoken expectations about actions (Andersen, 2009). As such, health professionals are stuck between professional ideas of documentation, and the governmental discourse of efficiency, standardization, and anonymous organizational roles.
The quality control documents construct the idea that health professionals bear sole responsibility for assessments, workflows, and professional language. In contrast, the method handbook constructs concrete practice guidelines in an organizational language DUVAL JENSEN ET AL.
| 7 of 11 that is oriented towards efficiency. Thus, health professionals seem to be caught between a rock and a hard place in an EHR-system that offers only the role of organizational employee supplying standardized services and quality control based on professional autonomy and responsibility. The dilemma is consistent with former research in policy and discourse that reveals conflicts and paradoxes in municipal healthcare (Dahl, 2019;Østensen et al., 2019). The professionals' voice is absent from the practical documents, which may lead to the assumption that the professionals take a subordinate position, allowing governmental problem representations to achieve legitimacy. As such, it seems that the subject of digital documentation is framed by governmental actors, deploying discourse on documentation for managerial purposes. Even though the selected documents in this analysis could indicate governmental control of digital documentation in healthcare, it is important to remember that "we are all subjects constituted in discourse" (Bacchi, 2009, p. 237), and this creates space for challenging that discourse in practice. Wilhelm

| Implications for further research
This study provides insights into how problem representations operate at microlevel in the form of discursive subjectification, and lived effects. It indicates that municipal healthcare practice transforms due to these effects. We propose that it is time for critical reflection on the effects of standardization. This requires further research into how digital documentation changes organizational priorities and work processes, the professionalism of the health profession, and coherence for citizens: for example, how health professionals interact with citizens whose needs do not fit into predefined categories, or how professional autonomy is maintained in a system offering only the role of the organizational employee who supplies standardized services.

| Strengths and limitations
In this study, the object of investigation was documents. In accordance with the WPR approach, we have suggested possible effects of municipal care practice resulting from this way of presenting digital documentation.
However, the approach cannot account for the concrete effects of implementing digital documentation.
The WPR approach is open to various analytical strategies. For instance, Arousell (2017) applied all questions to identify logic in an interview study, Walker (2020) emphasized two of the questions in an interview analysis, and Skovhus (2017) identified problem categories before analyzing documents. Our study included all questions to analyze the topic in multiple dimensions, including genealogical features, rationalities, and potential effects. As such, we have performed an integrated analysis by applying all questions to uncover a "tightly woven" representation of problem representations. Using poststructuralism as the theoretical basis for analysis, it becomes clear how practical documents not only represent the subject of digital documentation but also take part in producing digital documentation practices, bridging from text to possible real effects.

| CONCLUSION
Our study revealed three problem representations: lack of coherence in a complex healthcare system, lack of assessable data for management and political institutions to prioritize health services, and an inefficient healthcare system. Digital healthcare documentation stands uncontested as the solution to all three problem representations. Digital documentation co-constructs a fully standardized healthcare practice, covering a uniform design, specific terminology, well-described processes, and quality control by performance standards. Healthcare documentation is considered an essential part of healthcare practice; however, the standardized categories and classifications limit the language, practice, and detailed individualized healthcare. Thus, digital documentation can be understood as an organizational micromanagement approach as it assigns the health professional a subject position as an employee acting according to the organization's framework, instead of the profession's normative framework. Municipal healthcare is at risk of being fragmented due to digital documentation's focus on the organizational management of health with a task-oriented practice supplied by an anonymous health professional.

ACKNOWLEDGMENTS
This study was funded by The Health Foundation (Helsefonden), The